Neuroendoscope-assisted Evacuation of Large Intracerebral
Object: The aim of this study was to describe a new, minimally invasive technique for the endoscopic evacuation of intracerebral hematomas (ICHs) and the clinical and radiological outcomes in patients who underwent the procedure. The authors used a multifunctional three-in-one endoscopic instrument that combines a 0°, 4-mm rigid telescope, an irrigation cannula, and a cautery electrode.
Methods: In 13 patients a small keyhole craniotomy was made through noneloquent cortex to gain access to the hematoma. After opening the dura mater, a small cortical tunnel (~6 mm in diameter) was created using bipolar forceps and suction to enter into the clot. The three-in-one endoscope was then introduced to provide illumination and irrigation inside the cavity. The clot was safely aspirated under endoscopic vision and constant irrigation by performing microsurgical suction with the other hand. Hemostasis could be achieved using electrocautery and Surgicel. This technique eliminates the use of an endoscopic sheath, thus providing more maneuverability to the neurosurgeon. The brilliant illumination provided by the endoscope and the possibility of using electrocautery in the depths of the brain combined with the increased maneuverability make this technique valuable. Near-complete hematoma evacuation was achieved in 11 (85%) of 13 patients. There were four deaths (30%).
Conclusions: Safe and effective evacuation of large ICHs is possible by using the three-in-one endoscopic device. Appropriate indications for surgery in patients with large intracerebral hemorrhage must be developed.

Surgical evacuation of large spontaneous ICHs intuitively appeals to many neurosurgeons who routinely remove mass lesions from the brain (tumors, contusions, and subdural effusions). Convincing evidence that evacuation of these lesions leads to a better outcome in patients is lacking, however, despite many clinical trials. In a metaanalysis, Prasad, et al., compared data from four rigorously conducted trials and concluded that researchers in only one trial demonstrated statistically significant improved outcome for patients.

Many endoscopic techniques for the evacuation of ICHs have been described in the literature. Nonetheless, most neurosurgeons remain hesitant to perform these evacuations routinely, mainly given the absence of clear guidelines, but also because of inadequate control while performing the surgical procedure through traditional endoscopes. The need to control bleeding in the depths of the brain while working through long narrow channels coupled with the difficulties of handling multiple instruments and inadequate illumination in a blood-filled cavity have been formidable challenges. Here we describe a new surgical technique involving the use of a modified neuroendoscope, which overcomes some of these problems and thus gives neurosurgeons more control during the procedure.